Failure to Ensure Air Mattress Function for High-Risk Resident
Penalty
Summary
A resident with a history of pressure ulcers, chronic respiratory failure, anoxic brain damage, muscle wasting, and atrophy was identified as being at high risk for pressure ulcer development, with a Braden Scale score of 11. The resident was dependent on staff for turning and repositioning and had a physician order and care plan intervention for a low air loss mattress to be used as a pressure-distributing support surface. Despite these orders and interventions, multiple observations over two days revealed that the air mattress pump was not turned on while the resident was in bed, meaning the mattress was not providing the intended alternating pressure. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the air mattress pump should have been on at all times for this resident, as it was a key intervention to prevent further pressure ulcer development. The failure to ensure the air mattress was properly implemented and functioning as ordered and care planned constituted a lack of care consistent with professional standards of practice for a resident at high risk for pressure ulcers.